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Refinery accidents and investigations

Hydrocarbon Engineering,

Despite best efforts, the hydrocarbon industry is still experiencing incidents that affect production and the safety of personnel. In some cases, these incidents are catastrophic or could have been catastrophic if conditions were a bit difference.

When bad things happen and the event is examined, is the result of the examination going to be, ‘who is to blame’ or ‘where did the system fail?’

Studies show that human error is the most common cause. However, to truly understand the root cause of an incident, investigators will have to dig deeper and discover why the unsafe act was performed.

Multiple root cause findings from CSB investigations cite management failure. But is that going to be helpful in preventing a similar incident from happening?

Achieving consistency
How does an organisation ensure that activities produce specific results in a consistent manner on a sustainable basis? First, people should be told what to do. Second, people should be taught how to carry out the activities. Third, people should be held accountable for doing the things they have been taught to do.

Safety pyramid
Is it possible to discover breakdowns in the management system before a catastrophic incident occurs? Consider the safety pyramid, originated by H.W. Heinrich decades ago, which basically states that for a number of near misses/incidents, an organisation will experience a certain number of property damage incidents, then a certain number of personal injuries and finally a catastrophic incident.

Methods of investigation
What is the best way to investigate? There are software packages and numerous methodologies for conducting investigations. All investigation techniques generally start with a chronology of the incident and identify what happened, who did what, and when these things occurred. As the investigation continues, numerous causes are identified. Eventually, the investigation team will determine, based on the facts and the identified causes, the root cause of the incident. In almost every case, there will be a breakdown in one or more elements of the management system.

Investigating anything unusual that occurs and identifying elements of the risk management system that have failed are key components of the PSLG principles and the ‘learn from experience’ pillar of CCPS’ RBPS approach. When bad things happen and the event is examined, is the result going to be ‘who is to blame’ or ‘where did the system fail?’ Hopefully, the focus will be on system failure.

John M. Campbell & Company, from the March 2010 issue of Hydrocarbon Engineering

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